Short reports and correspondence

doi: 10.1054/bj ps.2000.3421

Unravelling a sticky problem

Sir, A common problem with the application of self-adhesive tape which is manufactured and presented as a roll (e.g. Mefix, pro- duced by SCA Mrinlycke Clinical Products AB, S-43535 Mrinlycke, Sweden) is the re-coiling of the tape to its original shape, after cutting and removal of the backing paper, causing the tape to adhere to itself. We suggest a technique for solving this sticky problem.

A length of tape is cut from the roll, suitable for the extent of the wound. The coil of tape is then folded in two or three approximately equidistant places along its length against the natural curvature (Fig. 1). The paper backing is removed leaving the tape hanging straight to allow easy application to the wound.

Figure 1--Appearance of tape after folding.

We believe this technique will help surgeons and dressers with the constant dilemma of how to apply self-adhesive tape slickly without having to abandon a length of tape irretrievably stuck to itself.

We acknowledge that this technique may not be new to some readers but have not seen it previously described and feel it may resolve difficulties for all those involved in dressing wounds.

Yours faithfully,

T. Beresford, Clinical Fellow in Plastic Surgery, M. M. Shibu, Locum Consultant Plastic Surgeon, Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Whitechapel, London E1 1BB, UK.

doi: 10.1054/bjps.2000.3422

Hands off!

Sir, Operating within the oral cavity for maxillofacial trauma usual- ly requires wide exposure, the use of drills, a clear view neces- sitating suction, water to cool the drill bit and the fractures to be stabilised during fixation. In our institution, these cases are often done without the help of an assistant other than a nursing sister, making it difficult to perform all the above tasks synchro- nously.

In an attempt to deal with this problem, we have found it use- ful to apply the Kilner cheek retractors to one or both oral com- missures and hook the free ends into the 'belts' of our gowns (Fig. 1). This frees not only both the operator's hands, but also allows any assistant to function more effectively. The operating field thus created is wide, allowing continuous inspection of the

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Figure 1--1ntraoperative use of two Kilner cheek retractors hooked into the belts of the gowns, whilst plating a parsymphyseal mandibular fracture.

fracture site and any occlusal abnormalities, whilst allowing for suctioning, drilling, etc.

Yours faithfully,

Paul J. Skoll FRCS, Donald A. Hudson FRCS, Department of Plastic, Reconstructive and Maxillo-Facial Surgery, H53 Old Main Building, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa.

doi: 10.1054/bjps.2000.3434

Preputial flap to hand and forearm

Sir, Various types of local and distant skin flaps have been devel- oped to treat hand injuries and their sequelae) Local flaps are mostly feasible for small defects only and can be associated with donor site morbidity, whereas most distant flaps are bulky and may have other problems such as hair growth, together with restriction of mobilisation, paraesthesia or hypoaesthesia and scarring at the donor site. 2'3 In order to overcome some of the disadvantages of other flaps and in cases where more than one flap was required, the preputial flap alone or in combination with the groin flap was used for providing skin cover over the hand and the wrist. Up to now the preputial flap has mainly been confined to urethroplasty or penile reconstruction, but a preputial free flap has been reported for the reconstruction of the lining of the oral cavity and pharynx. 4

The preputial flap is based on collaterals between branches of the external pudendal arteries and branches of the frenular artery (branch of the dorsal artery, which is a continuation of the internal pudendal artery). 5 The preputial flap was raised after a median dorsal slit in both the outer and the inner layers of the prepuce followed by a circumferential incision in the inner layer 2 mm above the coronal sulcus, thereby unfurling the inner layer of the prepuce. Depending on the area to be cov- ered, the flap was either kept unfurled or tubed when the area to be covered by the flap was comparatively small. Patients were catheterised normally for 24 h if the surgery was done under general anaesthesia. The flap was delayed after 2 weeks with complete division and inset at 17-20 days.

636 British Journal of Plastic Surgery

Anaesthesia for a preputial flap can be conveniently achieved by a combination of regional blocks, i.e. penile block with brachial or wrist block. A significant advantage associated with the preputial flap is that it can be raised by anyone who is familiar with the procedure of circumcision, whereas to raise a groin flap requires additional expertise. Freedom to mobilise the small joints of the hand is another advantage associated with the preputial flap. Early mobilisation of the small joints of the hand reduces the severity of the oedema that is likely to occur due to the dependent position of the recipient hand. Also, the posture of the patient is comfortable and the 'hand in pocket' position is very convenient to the patients. If a flap is required at two different sites in the same upper limb, a groin flap in combination with a preputial flap can be used. Significant dis- advantages are the slightly increased chance of infection if the patient does not maintain personal hygiene, and size restricting its use in large defects. Also, the flap is difficult to use in chil- dren and obviously it cannot be used in females!

Figure 1--Preputial flap attached to traumatic defect on ring finger.

A study comprised 15 patients varying from 14 years to 50 years of age. Six patients were operated for avulsion or crush injuries with exposed tendons and/0r bone in the acute stage of injury (Fig. 1). In two patients the first web space was recon- strncted after releasing contractures. In two patients flap cover was provided over the dorsum of the hand after removing tem- porary partial-thickness skin grafts with tenolysis of the exten- sor tendons. In another three patients, after releasing flexion contracture of the fingers, exposed tendons were covered with the preputial flap. In one patient tendons over the wrist were covered after failed partial-thickness skin grafting. In one patient both groin and preputial flaps were used to cover defects both over the wrist and on the dorsum of the thumb. Flaps with sizes varying from 4 • 3 cm to 7.5 x 7.0cm were raised. Flap size was dependent on the availability of preputial skin, the size of which was related to the size of the penis. No intraoperative dif- ficulties were encountered while raising the flaps.

Early ambulation was encouraged, which is an advantage over the groin flap where, due to stretching pain in the donor area, patients were reluctant to ambulate in the early postopera- tive period. Three patients developed minor infection with accompanying partial cut-through of sutures. All of these patients were successfully treated with local treatment for infec- tion and reattachment of flaps. No suppression of erection was felt necessary in the postoperative period.

Yours faithfully,

Devesh Sharma MS, Senior Resident Vinay Kumar Tiwari MS, MCh, Senior Consultant Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung Hospital, New Delhi, India.

References

1. Lesavoy MA. Local incisions and flap coverage. In: May JW, Littler JW, eds. Plastic Surgery, volume 7, 1st Ed. W.B. Saunders Company, 1990.

2. Lister G. The Hand: diagnosis and indications, 2nd Ed. Churchill Livingstone, 117-21.

3. Groner JP, Weeks PM. Skin and soft tissue replacement in the hand. In: Smith JW, Aston SJ, eds. Grabb and Smith's Plastic Surgery, 4th Ed. Little, Brown and Company, 1991.

4. Werker PMN, Terng ASC, Kon M. The prepuce free flap: dissection feasibility study and clinical application of a super-thin new flap. Plast Reconstr Surg 1998; 102: 1075-82.

5. Juskiewenski S, Vaysse Ph, Moscovici J, Hammoudi S, Bouissou E. A study of the arterial blood supply to the penis. Anat Clin 1982; 4: 101.